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Radiographic Evaluation of Dorsal Screw Penetration After Volar Fixed-Angle Plating of the Distal Radius: A Cadaveric Study

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HAND

Abstract

Introduction

Extensor tendon irritation and attritional tendon ruptures are potentially serious complications after open reduction and internal fixation of distal radius fractures. These complications are well recognized after dorsal plating of distal radii; and these are now being reported after errant screw placement during volar fixed-angle plating. Intraoperative detection of improper screw placement is critical, as corrective action can be taken before completion of the operative procedure. The purpose of this study was to define the extensor tendon compartments at risk secondary to dorsal screw penetration and to compare pronation and supination fluoroscopic images with standard lateral images in demonstrating dorsal screw prominence during volar locked plating.

Methods

Eight fresh-frozen human cadaveric upper extremities underwent fixation with a volar, fixed-angle distal radius locked plate (Wright Medical Technology, Arlington, TN). Three fluoroscopic views (lateral, supinated, and pronated) followed by dorsal wrist dissections were compared to determine accuracy in detecting dorsal screw prominence and extensor tendon compartment violation. Subsequently, screws measuring 2, 4, 6, 8, and 10(mm longer than the measured depths were sequentially inserted into each distal locking screw, with each image deemed either "in" (completely inside the bone) or "out" (prominent screw tip dorsally-would typically be exchanged for a shorter screw intraoperatively).

Results

The radial most distal locking screw (position 1) violated either the first (25%) or second (75%) extensor tendon compartments. The average screw prominence required for radiographic detection was: 6.5(mm for lateral views and 2(mm for supinated views. Pronated views did not identify prominent screws. Screws occupying plate position 2 consistently entered Lister's tubercle, with 5/8 exiting the apex and 3/8 exiting the radial base. The average screw prominences for radiographic detection were: 2.75(mm-lateral views and 3.0(mm-supinated views. Although the screws entered the second dorsal compartment, they did not encroach upon either of the tendons. Screws occupying plate position 3 violated the third extensor tendon compartment in 7/8 specimens with 1/8 exiting the Ulan base of Lister's tubercle. The average screw prominences for radiographic detection were: 3.5(mm-lateral views and 2.5(mm-pronated views. Supinated views did not identify prominent hardware. Screws occupying plate position 4 all violated the IV dorsal extensor compartment-2/8 screws were noted to tent the posterior interosseous nerve. The average screw prominences required for radiographic detection were: 4.0(mm-lateral views and 2.5(mm-pronated views. The supinated views did not identify prominent screws.

Conclusions

Volar fixed-angle plating has shown great promise in the advancement of distal radius fracture management. We have seen in our referral practices and in the literature an increase in the number of extensor tendon complications arising from unrecognized dorsally prominent screws, pegs, or tines. Standard PA and lateral radiographs cannot adequately visualize screw position and length secondary to the complex geometry of the dorsal cortex. We believe this study supports the routine application of intraoperative, oblique pronosupination fluoroscopic imaging for enhanced confirmation of distal locking screw position and length.

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References

  1. Axelrod TS, McMurtry RY. Open reduction and internal fixation of comminuted, intra-articular fractures of the distal radius. J Hand Surg 1990;15A:1–11.

    Google Scholar 

  2. Beharrie Aw, Beredjiklian PK, Bozentka DJ. Functional outcomes after open reduction and internal fixation for treatment of displaced distal radius fractures in patients over 60 years of age. J Orthop Trauma 2004;18(10):680–6.

    Article  PubMed  Google Scholar 

  3. Bell JSP, Wollstein R, Citron ND. Rupture of the flexor pollicis longus tendon: a complication of volar plating of the distal radius. J Bone Jt Surg Br 1998;80B:225–6.

    Article  Google Scholar 

  4. Boyer MI, Korcek KJ, Gelberman RH, Gilula LA, Ditsios K, Evanoff BA. Anatomic, tilt x-rays of the distal radius: an ex vivo analysis of surgical fixation. J Hand Surg 2004;29A:116–22.

    Google Scholar 

  5. Jakob M, Rikli D, Regazzoni P. Fractures of the distal radius treated by internal fixation and early function: a prospective study of 73 consecutive patients. J Bone Jt Surg Br 2000;82B(3):340–4.

    Article  Google Scholar 

  6. Jupiter JB. Plate fixation of the distal aspect of the radius: relative indications. J Orthop Trauma 1999;13(8):559–69.

    Article  PubMed  CAS  Google Scholar 

  7. Jupiter JB, Fernandez DL, Choon-Lai T, Fellman T, Ring D. Operative treatment of volar intra-articular fractures of the distal end of the radius. J Bone Jt Surg Am 1996;78A(12):1817–28.

    Google Scholar 

  8. Kamano M, Honda Y, Kazuki K, Yasuda M. Palmar plating for dorsally displaced, fractures of the distal radius. Clin Orthop 2002;397:403–8.

    Article  PubMed  Google Scholar 

  9. Kambouroglou GK, Axelrod TS. Complications of the AO/ASIF titanium distal radius plate system in internal fixation of the distal radius: a brief report. J Hand Surg. 1998;23A:737–41.

    Google Scholar 

  10. Liporace FA, Gupta S, Jeong GK, Gerard K, Stracher M, Kummer F, et al. A biomechanical comparison of a dorsal 3.5 mm T-plate and a volar, fixed-angle plate in a model of dorsally unstable distal radius fractures. J Orthop Trauma 2005;19(3):187–91.

    Article  PubMed  Google Scholar 

  11. McKay SD, MacDermid JC, Roth JH, Richards RS. Assessment of complications of distal radius fractures and development of a complications checklist. J Hand Surg 2001;26A:916–22.

    Google Scholar 

  12. Nana AD, Joshi A, Lichtman DM. Plating of the distal radius. J Am Acad Orthop Surg. 2005;13:159–71.

    PubMed  Google Scholar 

  13. Nunley JA, Rowan PR. Delayed rupture of the flexor pollicis longus tendon after, inappropriate placement of the π plate on the volar surface of the distal radius. J Hand Surg 1999;24A:1279–80.

    Google Scholar 

  14. Orbay JL, Fernandez DL. Volar fixation of dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg 2002;27A:205–15.

    Google Scholar 

  15. Orbay JL, Fernandez DL. Volar fixed angle plate fixation for unstable distal radius, fractures in the elderly patient. J Hand Surg 2004;29A:96–102.

    Google Scholar 

  16. Rozental TD, Beredjiklian PK, Bozentka DJ. Functional outcomes and complications following two types of dorsal plating for unstable fractures of the distal part of the radius. J Bone Jt Surg Am 2003;85A:1956–60.

    Google Scholar 

  17. Smith DW, Henry MH. The 45° pronated oblique view for volar fixed-angle plating, of distal radius fractures. J Hand Surg 2004;29A:703–6.

    Google Scholar 

  18. Weiland AJ. External fixation, not ORIF, as the treatment of choice for fractures of the distal radius. J Orthop Trauma 1999;13(8):570–2.

    Article  PubMed  CAS  Google Scholar 

  19. Yang Z, Mann FA, Gilula LA, Haerr C, Larsen CF. Scaphopisocapitate aligment: criterion to establish a neutral lateral view of the wrist. Radiology 1997;205:865–9.

    PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Department of Orthopedic Surgery, Cleveland Clinic, 9500 Euclid Avenue A41, Cleveland, OH, 44195, USA

    Steven D. Maschke

  2. Section of Hand & Upper Extremity Surgery, Department of Orthopedic Surgery, Cleveland Clinic, 9500 Euclid Avenue A40, Cleveland, OH, 44195, USA

    Peter J. Evans & Jeffrey N. Lawton

  3. Case Western Reserve, University School of Medicine, Cleveland, OH, USA

    David Schub

  4. Lerner College of Medicine, NA24, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA

    Richard Drake

Authors
  1. Steven D. Maschke
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  2. Peter J. Evans
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  3. David Schub
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  4. Richard Drake
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  5. Jeffrey N. Lawton
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Correspondence to Jeffrey N. Lawton.

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Maschke, S.D., Evans, P.J., Schub, D. et al. Radiographic Evaluation of Dorsal Screw Penetration After Volar Fixed-Angle Plating of the Distal Radius: A Cadaveric Study. HAND 2, 144–150 (2007). https://doi.org/10.1007/s11552-007-9038-2

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  • DOI: https://doi.org/10.1007/s11552-007-9038-2

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